RIVERSIDE UNIVERSITY HEALTH SYSTEM – MEDICAL CENTER

1. Top 10 Disparities

The following table lists the ten largest health equity disparities identified for this reporting period.

Disparities for each hospital equity measure are identified by comparing the rate ratios by stratification groups. Rate ratios are calculated differently for measures with preferred low rates and those with preferred high rates. Rate ratios are calculated after applying the California Health and Human Services Agency's "Data De-Identification Guidelines (DDG)," dated September 23, 2016.

The table below highlights the ten widest health equity disparities identified by hospitals and hospital systems during this reporting period. Measure names have been shortened for display purposes. To view each measure in full, please download the complete Hospital Equity Report using the link below.

Measure	Stratification	Stratification Group	Stratification Group Rate	Reference Group	Reference Rate	Rate Ratio
1. HCAI 30-Day readmission	Expected Payor	Medicare	19.5%	Private	6.7%	2.90
2. HCAI 30-Day readmission	Expected Payor	Medicaid	14.6%	Private	6.7%	2.20
3. HCAI 30-Day readmission	Preferred Language	English Language	16.0%	Spanish Language	15.2%	2.10
4. AHRQ PSI surgical death rate	Expected Payor	Medicare	316.7%	Medicaid	164.4%	1.90
5. HCAI 30-Day readmission	Age (excluding maternal measures)	65 and older	18.7%	18 to 34	9.8%	1.90
6. HCAI 30-Day readmission	Age (excluding maternal measures)	50 to 64	17.9%	18 to 34	9.8%	1.80
7. HCAI 30-Day readmission	Expected Payor	Self-Pay	11.2%	Private	6.7%	1.70
8. AHRQ PSI surgical death rate	Sex Assigned at Birth	Male	264.4%	Female	169.2%	1.60
9. HCAI 30-Day readmission	Expected Payor	Self-Pay	11.2%	Private	6.7%	1.60
10. HCAI 30-Day readmission	Age (excluding maternal measures)	35 to 49	14.9%	18 to 34	9.8%	1.50

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2. Equity Plan

Review of Top Disparities and Targeted Interventions at Riverside University Health System-Medical Center
Following a comprehensive review of our top 10 disparities, it was identified that eight are related to 30-day readmissions. Riverside University Health System-Medical Center (RUHS-MC) has maintained a dedicated Readmission Reduction Task Force that has met monthly over the past two years to systematically analyze and address 30-day readmissions.
While our efforts have traditionally been disease-specific rather than broadly targeting the identified disparities, our primary focus has been on heart failure, the leading diagnosis contributing to readmissions and significantly impacting our overall rates. Our objective is to improve the heart failure readmission rate from 10% to 30% by the end of 2025.
Key initiatives include:
• Daily EPIC-generated reports monitoring heart failure readmissions.
• Implementation of an EPIC alert banner to notify providers of patients with a recent 30-day readmission, enhancing provider awareness.
• An upcoming Rapid Improvement Event (RIE) aimed at establishing best practices to provide patients with resources potentially preventing readmissions, such as medication adherence, addressing social determinants of health (including homelessness, transportation barriers, home health needs, and substance use disorders).
• The heart failure care team actively engages admitted patients to identify and mitigate barriers to successful discharge and recovery.
At RUHS, a significant challenge is that many index admissions originate from patients unaffiliated with our RUHS Community Clinics, complicating efforts for post-discharge follow-up care. To address this, RUHS has partnered with Inland Empire Health Plan—our largest network provider—to enhance collaboration and optimize care delivery for our shared patient population. This partnership aims to ensure equitable access to community resources regardless of age, race, language preference, gender assigned at birth, or payer source.
Rapid Improvement Event for Readmission Reduction
Through collaboration with the RUHS-MC Value Stream team, we have identified the need for a Rapid Improvement Event focused on standardizing the process for identifying and reducing 30-day readmissions. The multidisciplinary team includes Emergency Department physicians and nursing leadership, case management/social workers, hospitalists, community health workers, substance use navigators, representatives from community health clinics, and RivCO One partners.
Currently, the absence of a standardized readmission identification process contributes to elevated readmission rates, which adversely affect patient experience, Leapfrog scores, reimbursement, and CMS Star ratings. Our goal is to implement a uniform process to accurately track and reduce 30-day readmissions, thereby enhancing patient outcomes and institutional performance metrics.
Addressing PSI-04: Death Rate Among Surgical Inpatients with Serious Treatable Complications
Regarding the two remaining disparities, specifically PSI-04 related to mortality among surgical inpatients with serious treatable complications, our analysis of 34 AHRQ PSI-04 cases identified sepsis as the predominant indicator (15 cases), often present on admission.
RUHS-MC is committed to delivering exceptional care to all patients with sepsis, irrespective of demographic or socioeconomic factors. As a testament to our quality, RUHS-MC has maintained Joint Commission certification in Disease-Specific Sepsis Care since 2017.
Our CMS SEP-1 Core Measure Bundle compliance consistently surpasses internal benchmarks and approaches CMS targets. Notably, our performance improved to 86% in Q1 2025, compared to an average of 73% in 2024. We remain dedicated to sustaining these improvements to meet and exceed CMS benchmarks.

3. Structural Measures

Centers for Medicare & Medicaid Services (CMS) Hospital Commitment to Health Equity Structural (HCHE) Measure	Yes/No
Our hospital system strategic plan identifies priority populations who currently experience health disparities	Yes
Our hospital system strategic plan identifies healthcare equity goals and discrete action steps to achieve these goals	Yes
Our hospital system strategic plan outlines specific resources that have been dedicated to achieving our equity goals	Yes
Our hospital system strategic plan describes our approach for engaging key stakeholders, such as community-based organizations	Yes
Our hospital strategic plan identifies healthcare equity goals and discrete action steps to achieve these goals	Yes
Our hospital system has training for staff in culturally sensitive collection of demographics and/or social determinant of health information	Yes
Our hospital system inputs demographic and/or social determinant of health information collected from patients into structured, interoperable data elements using a certified EHR technology	Yes
Our hospital system stratifies key performance indicators by demographic and/or social determinants of health variables to identify equity gaps and includes this information in hospital performance dashboards	Yes
Our hospital system participates in local, regional or national quality improvement activities focused on reducing health disparities	Yes
Our hospital system senior leadership, including chief executives and the entire hospital board of trustees, annually reviews our strategic plan for achieving health equity	Yes
Our hospital system senior leadership, including chief executives and the entire hospital board of trustees, annually reviews key performance indicators stratified by demographic and/or social factors	Yes

RIVERSIDE UNIVERSITY HEALTH SYSTEM – MEDICAL CENTER